Information Collection

Data Collection for Education and Outreach for the Yello System (CMS-10872)

IC 283056 under ICR 202610-0938-001 · OMB 0938-1185.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10872 CMS Applicant Information Collection Form Data Collection for Education and Outreach for the Yello System (CMS-10872)	Form and Instruction
CMS-10872 CMS Applicant Information Collection Form CMS-10872. Yello Collection Instrument.docx	Form and Instruction
CMS-10872.Fast Track Submission Template.docx CMS-10872.Fast Track Submission Template	IC Document

IC Title:

Agency IC Tracking Number:

OHI

IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-10872				Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title: OPM GOVT-5

FR Citation: 80 FR 74815

Number of Respondents: 284,000

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Requested	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	284,000	284,000
Annual IC Time Burden (Hours)	9,488	9,488
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
CMS-10872.Fast Track Submission Template		10/14/2026

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.

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